Sideline Injury Evaluation Note (Acute On-Field)

Date: [Date (YYYY-MM-DD)] Time of Evaluation: [Local time (HH:MM)] Time Zone: [Time zone]

Athlete Name: [Full name] DOB: [YYYY-MM-DD] ID/MRN: [Identifier]

Team/Organization: [Team/Organization] Sport: [Sport] Position: [Position/Role]

Venue/Location: [Venue and field/court area] Event Type: [game / practice / other]

Evaluator: [Name, credentials] Additional Responders: [Names and roles] (Include only if others assisted)

Late Entry: [Documentation time and source of timing details] (Include only if documentation occurred after the event)

Injury Event Summary

Chief Complaint: [Body area and primary symptom]

[Mechanism narrative: contact/non-contact, direction of force, body position, protective equipment in use, whether play stopped immediately, key witness observations] (2–5 sentences; keep concise and factual)

Timeline: (Include only applicable time points)

• Injury Time: [HH:MM]
• Evaluation Initiated: [HH:MM]
• Removed From Play: [HH:MM]
• EMS Activated: [HH:MM]
• EMS Arrival: [HH:MM]
• EMS Departure: [HH:MM]

Triage and Catastrophic Screen

[No catastrophic injury concern; primary survey not indicated] (If clearly minor with no concerning features, document as a single line and omit bullets below)

• Responsiveness (AVPU): [Alert / Voice / Pain / Unresponsive] at [HH:MM]
• Airway: [Patent / Compromised] Breathing: [Adequate / Inadequate] Circulation: [Adequate / Concern]
• Cervical Spine Precautions Indicated: [Yes / No] (If yes, specify stabilization method and time initiated)
• (For head/neck mechanism or altered mental status, document the following)
• Loss of Consciousness: [Present / Absent / Unknown] Bilateral Neurologic Complaints: [Present / Absent] Midline Spine Pain: [Present / Absent] Spinal Deformity: [Present / Absent]
• EAP Activated: [Yes / No] (If yes: [Roles assigned, EMS contact time, equipment used, stabilization steps])

Signs and Symptoms

Athlete-Reported: (If athlete cannot provide symptoms, document why and rely on observed signs)

• Pain: [Location, quality, severity (0–10), onset/duration]
• Functional Limitations: [Specific limitations described]
• Neurologic Symptoms: [Headache / Dizziness / Confusion / Visual changes / Numbness / Tingling / None]
• Other Key Symptoms: [As stated] (Use direct quotes only for medically significant statements such as amnesia)

Observed Signs:

• [Observed finding: gait instability, swelling, deformity, guarding, behavior changes, altered responsiveness] (Note observer if not evaluator)

Pertinent Negatives: (Include only if actually assessed)

• [Relevant negatives: no LOC observed, denies neck pain, no midline tenderness, no neuro deficits]

Focused Sideline Exam

General Observations: [Distress level: mild/moderate/severe] [Ambulation status] [Assistive needs]

Vitals: [HR, BP, RR, SpO2, Temp at HH:MM] (Include only if obtained)

Involved Region Exam: (For each element, document normal, abnormal with description, or not assessed with reason)

• Inspection: [Swelling, deformity, ecchymosis, wounds, effusion, alignment]
• Palpation: [Point tenderness location and severity, crepitus, step-off, warmth]
• Range of Motion: [Full / Limited by pain / Limited by mechanical block] [Active/Passive]
• Strength (gross): [Normal / Reduced] [Key movements tested]
• Special Tests: [Test name(s) and results] (Include only if performed)
• Distal Neurovascular: [Pulses, capillary refill, sensation, motor] (For extremity injuries)

Concussion Evaluation

(Include this section only if head impact, whiplash mechanism, observed neurologic change, or athlete-reported neurologic symptoms; otherwise omit entirely)

• On-field Signs Prompting Removal: [Observed sign(s) and time] Returned to Play Before Recognition: [Yes / No]
• Emergency Red Flags: [Worsening headache / Repeated vomiting / Declining mental status / Focal deficit / Prolonged LOC / Seizure]: [Present / Absent] (If present, prioritize EAP/EMS documentation)
• Cognitive Screen: [Orientation, immediate/delayed memory, concentration results]
• Balance/Gait: [Tandem gait, single-leg stance, gait assessment results]
• Symptom Inventory: [Symptom count and severity summary]
• Tool Used: [Name/version, subtests completed, limitations encountered]
• Serial Re-evaluations: [Time-stamped repeat findings] (Include only if performed)
• Concussion Status: [Suspected / Diagnosed / Not suspected at this time] (If suspected or diagnosed, confirm no same-day return to play)

Exertional/Environmental Illness

(Include only for collapse, heat exposure with CNS signs, syncope, suspected sickling/asthma, or lightning exposure; otherwise omit entirely)

• Heat Illness: CNS dysfunction: [Present / Absent]; Core temp: [Value, method]; Cooling measures: [Method(s), start time]
• Cardiac Arrest: Collapse: [HH:MM]; CPR start: [HH:MM]; AED applied: [HH:MM]; Shock times: [List]; ROSC: [HH:MM / Not achieved]
• Lightning Exposure: [Shelter status, strike proximity/mechanism, injury details]

Clinical Impression

• [Problem 1] — [Clinical impression or suspected diagnosis]. Supporting findings: [Key positives/negatives]. Immediate risks: [If any]
• [Problem 2] — [As above]

(List in descending order of acuity; acknowledge diagnostic constraints: limited time, environment, no imaging, athlete guarding)

Interventions Performed

(Include only if interventions were provided; otherwise omit entirely)

• [On-field care: immobilization, splinting, bracing, taping, crutches, ice, compression, wound care] [Location, time]
• [Emergency interventions: CPR, AED, airway management] [Details, times]
• [Medication: drug, dose, route, time, indication] [Response, adverse effects]
• [Treatment offered but declined: document athlete capacity and refusal]

Participation Decision

Disposition: [Continued play without restriction / Continued play with limitation / Removed from play (same-day restriction) / Disqualified from event] due to [reason tied to safety/findings]

Decision by: [Name, role] Consulted: [Names/roles / None]

Rationale: [Objective findings, risk considerations, policy/protocol alignment] (If permitting same-day non-concussion return, document criteria met and monitoring plan)

Disposition and Follow-Up

Immediate Disposition: [Returned to sideline with monitoring / Returned home with supervision / Referred to urgent care/ED / EMS transport to destination]

Follow-Up Plan: [When/where re-evaluation; imaging/tests ordered or recommended; activity restrictions; return precautions requiring ED evaluation]

Released To: [Name and relationship] at [HH:MM]

Instructions Provided: [Verbal / Written / Printed assessment results] Understanding Confirmed: [Yes / No]

Notifications

(Include only if notifications occurred; otherwise omit entirely)

• Parent/Guardian: [Notified at HH:MM; summary of information provided]
• Coach/Administration: [Notified at HH:MM; summary]
• Refused Evaluation/Treatment or Left Against Advice: [Capacity assessment, risks discussed, efforts to persuade, witnesses]

Authentication

Evaluator Signature: [Name, credentials] Date/Time Signed: [YYYY-MM-DD HH:MM]

Scribe/Transcription Attestation: [Attestation statement] (Include only if applicable)

(Addendums must be added as labeled addendums with current date/time and reason; do not overwrite original content)